MEDICARE: MR. HERMAN TED THOMPSON LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP2769	MN

General Provider Information

NPI Number	:	1902951031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HERMAN TED THOMPSON LP

Provider Business Mailing Address
First Line	:	1516 W LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2554
Country	:	US
Telephone Number	:	612-821-2099
Fax Number	:	612-821-2099

Provider Business Practice Location Address
First Line	:	1516 W LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2554
Country	:	US
Telephone Number	:	612-821-2099
Fax Number	:	612-821-2099

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/09/2007

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